Group Life Insurance Certificate. The Independent School District of Boise City

Transcription

1 Group Life Insurance Certificate The Independent School District of Boise City

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3 IMPORTANT NOTICES If you reside in one of the following states, please read the important notices below: Arizona, Florida and Maryland residents: The group policy is issued in the state of IDAHO and will be governed by its laws. If you reside in a state other than IDAHO, this certificate of insurance may not provide all of the benefits and protections provided by the laws of your state. PLEASE READ YOUR CERTIFICATE CAREFULLY. Texas residents: IMPORTANT NOTICE: To obtain information or make a complaint: You may call the toll-free telephone number for information or to make a complaint at You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights or complaints at You may write the Texas Department of Insurance: P O Box Austin, TX FAX # (512) PREMIUM OR CLAIM DISPUTES: Should you have a dispute concerning your premium or about a claim you should contact the agent or company first. If the dispute is not resolved, you may contact the Texas Department of Insurance. AVISO IMPORTANTE: Para solicitar información o presentar una queja: Usted puede llamar al numero de telefono gratis para información o pare someter una queja al Puede comunicarse con el Departamento de Seguros de Texas para obtener información sobre compañías, coberturas, derechos o quejas llamando al También puede escribir al Texas Department of Insurance (Departamento de Seguros de Texas): P O Box Austin, TX FAX: (512) CONFLICTOS POR PRIMAS O RECLAMACIONES: En caso de tener un conflicto relacionado con su prima o una reclamación, debe comunicarse primero con el agente o la compañía. Si el conflicto no se resuelve, usted puede comunicarse con el Departamento de Seguros de Texas.

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5 Washington Residents: (In Accordance With WAC , 620, 650, 730) The accelerated life benefit in this policy does not and is not intended to qualify as long-term care under Washington state law. Washington state law prevents this accelerated life benefit from being marketed or sold as long-term care. If an Insured receives payment of accelerated benefits from a life insurance policy, he or she may lose the right to receive certain public funds, such as Medicare, Medicaid, Social Security, Supplemental Security, Supplemental Security Income (SSI), and possibly others. Also, receiving accelerated benefits from a life insurance policy may have tax consequences for the Insured. We cannot give advice about this. The Insured may wish to obtain advice from a tax professional or an attorney before he or she decides to receive accelerated benefits under a life policy.

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7 NOTICE Benefits paid under the Accelerated Benefits provision will reduce the Death Benefit payable for life insurance. Benefits payable under the Accelerated Benefits provision may be taxable. If so, the Employee or the Employee's beneficiary may incur a tax obligation. As with all tax matters, an Employee should consult with a personal tax advisor to assess the impact of this benefit. Accelerated Benefits are not payable if life insurance coverage under the Policy is not in force. TL

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9 FOREWORD Life insurance provides individuals and their families with financial protection. The Life Insurance Benefit described in this booklet will help secure your family's financial security in the event of your death. The need for life insurance protection depends on individual circumstances and financial situations. Your Employer is offering you the opportunity to purchase this insurance to make your benefit program more comprehensive and responsive to your needs. The following pages describe the main provisions of the group term life insurance plan available to you. Any insurance benefit described in the following pages will apply to you only if you have elected that benefit and have authorized payroll deduction for the required premium.

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11 LIFE INSURANCE COMPANY OF NORTH AMERICA 1601 CHESTNUT STREET GROUP INSURANCE PHILADELPHIA, PA CERTIFICATE (800) TDD (800) A STOCK INSURANCE COMPANY We, the LIFE INSURANCE COMPANY OF NORTH AMERICA, have issued a Group Policy, FLX , to TRUSTEE OF THE GROUP INSURANCE TRUST FOR EMPLOYERS IN THE ELEMENTARY AND SECONDARY SCHOOLS-FIN.INS. AND R INDUSTRY on behalf of The Independent School District of Boise City. This certificate describes the benefits and basic provisions of your coverage. You should read it with care so you will understand your coverage. This is not the insurance contract. It does not waive or alter any of the terms of the Policy. If questions arise, the Policy will govern. You may examine the Policy at the office of the Policyholder or the Administrator. This certificate replaces any and all certificates which may have been issued to you in the past under the Policy. Matthew G. Manders, President TL

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13 TABLE OF CONTENTS SCHEDULE OF BENEFITS...1 WHO IS ELIGIBLE...2 WHEN COVERAGE BEGINS...2 WHEN COVERAGE ENDS...3 WHEN COVERAGE CONTINUES...3 LIFE INSURANCE BENEFITS...3 LIFE INSURANCE EXCLUSIONS...5 ACCIDENT INSURANCE BENEFITS...5 ACCIDENT INSURANCE EXCLUSIONS...5 CLAIM PROVISIONS...6 ADMINISTRATIVE PROVISIONS...8 GENERAL PROVISIONS...8 DEFINITIONS...9

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15 SCHEDULE OF BENEFITS Policy Effective Date: September 1, 1996 Certificate Effective Date: May 1, 2012 Policy Anniversary Date: September 1 Policy Number: FLX Class Definition You are eligible for insurance if you are a member of the class defined below. All retirees of the Employer who elect Life and AD&D coverage through PERSI LIFE INSURANCE BENEFITS If an Insured is eligible under one Class of Eligible Employees and later becomes eligible under a different Class of Eligible Employees, changes in his or her insurance due to the class change will be effective on the first date you are in Active Service on or after the date of the change in class. Employee Benefits Amount of Insurance $25,000 Minimum Benefit: $25,000 Maximum Benefit: $25,000 Terminal Illness Benefit Maximum Benefit: Spouse Benefits Amount of Insurance $5,000 Guaranteed Issue Amount: $5,000 Maximum Benefit: $5,000 50% of the Maximum Benefit applicable to your Life Insurance Benefits. Terminal Illness Benefit Maximum Benefit: 50% of the Maximum Benefit applicable to Spouse Life Insurance Benefits. The Life Insurance Coverage Amount will terminate for an Employee age 75 and over and for a Spouse age 75 and over. Dependent Child Benefits Amount of Insurance $3,000 The Maximum Benefit for a Dependent Child who is less than 6 months old is $1,000. All Dependent Child benefits are Guaranteed Issue. 1

16 ACCIDENT INSURANCE BENEFITS Employee Benefits Amount of Insurance Same as Life Insurance Benefits WHO IS ELIGIBLE Classes of Eligible Persons A person may be insured only once under the Policy as an Employee, Spouse or Dependent Child, even though he or she may be eligible under more than one class. Employee If you qualify under the Class Definition shown in the Schedule of Benefits, you are eligible to be insured under the Policy on the Policy Effective Date. Spouse Your Spouse is eligible to be insured on the date you are eligible or the date he or she becomes your Spouse, if later. For eligibility purposes, your Spouse must be a lawful Spouse and not legally separated from, divorced from, or widowed by you. He or she must be under age 75 to be eligible. Dependent Child Your Dependent Child is eligible to be insured on the date you are eligible or the date the child becomes a Dependent Child, if later. In no event will a Dependent Child be eligible to be insured more than once under the Policy. TL WHEN COVERAGE BEGINS If you are required to contribute to the cost of this insurance, you may elect insurance for yourself, your Spouse and Dependent Children only by authorizing payroll deduction in a form approved by the Employer and us. The effective date of this insurance depends on the date and amount of insurance elected. If you elect coverage within 31 days after you, your Spouse or Dependent Children are eligible, any amount that does not exceed the Guaranteed Issue Amount is effective on the latest of the following dates. 1. The Policy Effective Date. 2. The date payroll deduction is authorized for this insurance. 3. The date the completed enrollment form is received by the Employer or us. If you or your Spouse elect insurance in an amount that exceeds the Guaranteed Issue Amount or if your enrollment form is received more than 31 days after you become eligible to elect coverage, this insurance is effective on the date we agree in writing to provide this coverage. We will require an eligible person to satisfy the Insurability Requirement before we agree to insure him or her. If coverage for a Dependent Child is in force and another Dependent Child becomes eligible, coverage for that child is effective on the date he or she qualifies as a Dependent Child. If you, your Spouse or Dependent Children are not in Active Service on the date insurance would otherwise go into effect, it will be effective on the date you, your Spouse or Dependent Children return to Active Service. TL

17 WHEN COVERAGE ENDS Coverage will end on the earliest of the following dates. 1. The date you are eligible for coverage under a plan intended to replace this coverage. 2. The date we terminate the Policy. 3. The date you, your Spouse or Dependent Children are no longer eligible. 4. The date you reach age The day after the end of the period for which required premiums are paid. 6. The date the Employer cancels participation under the Policy. 7. The date your coverage ends, for any insured Spouse or Dependent Child. TL WHEN COVERAGE CONTINUES Extended Death Benefit with Waiver of Premium Extended Death Benefit If you become Disabled and are less than age 60, the Life Insurance Benefits shown in the Schedule of Benefits will be extended without premium payment until the earlier of the following dates: 1. The date you are no longer Disabled. 2. The date you fail to qualify for Waiver of Premium or fail to provide proof of Disability as indicated under Waiver of Premium. Amount of Insurance If you die while you are Disabled and coverage is extended under this provision, we will pay a Death Benefit equal to the amount in effect on the date you became Disabled. However, the Life Insurance Benefit will be subject to the provisions of the Policy that reduce the coverage amount because of age, retirement, payment of an Accelerated Benefit or a change in class. Automatic increases in Life Insurance Benefits will end while premiums are waived. We will pay benefits only if due proof of your continuous Disability is received within one year of the date of the loss. Disability / Disabled means because of Injury or Sickness you are unable to perform all the material duties of your Regular Occupation; or are receiving disability benefits under the Employer s plan. Regular Occupation means the occupation you routinely perform at the time the Disability begins. We will consider the duties of the occupation as it is normally performed in the general labor market in the national economy. Waiver of Premium If you are an Employee under age 60 and your Active Service ends due to Disability, Life Insurance Benefits will continue for you, your Spouse and Dependent Children, if any until the earliest of the following dates. 1. The date you are no longer Disabled. 2. The day after the end of the period for which required premiums are paid. 3. The date you no longer qualify for Waiver of Premium days. If you die while premiums are waived, we will pay a Death Benefit only if due proof of continuous Disability is received within one year of your death. 3

18 In order to qualify for Waiver of Premium, you must submit due proof that you have been Disabled for 6 months. Such proof must be submitted to us no later than 9 months from the date your Active Service ends. Premiums will be waived from the date the Insurance Company agrees in writing to waive your premiums. After premiums have been waived for 12 months, they will be waived for future periods of 12 months if you remain Disabled and submit due proof that your Disability continues. Satisfactory proof must be submitted to us 3 months before the end of the 12 month period. The Death Benefit will be equal to the Life Insurance Benefit in effect on the date you became Disabled. However, this benefit will be subject to the provisions of the Policy that reduce or terminate coverage because of age, retirement, acceleration or a change in eligible class. Automatic increases in Life Insurance Benefits will end while premiums are waived. Termination of Waiver Your insurance will end on the earliest of the following dates. 1. The date you are no longer Disabled. 2. The date you refuse to submit to any physical examination required by us. 3. The last day of the 12 month period of Disability during which you fail to submit satisfactory proof of your continued Disability days. TL WHAT IS COVERED LIFE INSURANCE BENEFITS Death Benefit If an Insured dies, we will pay the Life Insurance Benefit in force for that Insured on the date of his or her death. TL Seatbelt Benefit We will pay 10% of your Life Insurance Benefits in force on the date of an Accident or $10,000, if less, if you die as a result of an Accident and the following conditions are met. 1. The Accident occurs while you are covered as an Employee under the Policy. 2. You are driving or riding as a passenger in a Private Passenger Car, the car is equipped with seatbelts and the seatbelt was in actual use and properly fastened at the time of the Accident. The use and position of the seatbelt must be certified in the official report of the Accident. However, if an official report is not available or it is unclear if you were properly wearing a seatbelt, we will pay $1,000. If such report indicates that a seatbelt was not in use, we will not pay any benefits under this provision. The Seatbelt Benefit will not be paid for an Accident which occurs while you are participating in a race, speed or endurance test. "Private Passenger Car" means a validly registered four-wheel vehicle limited to private passenger cars, station wagons, jeeps, pick-up trucks and van-type cars. TL

19 Accelerated Benefits Any benefits payable under this Accelerated Benefits provision will reduce the Death Benefit payable for Life Insurance. Any automatic increases in Life Insurance Benefits will end when benefits are payable under this provision. Terminal Illness Benefit We will pay a Terminal Illness Benefit if we determine you or your Spouse are Terminally Ill. The amount of this benefit is 50% of the Life Insurance Benefit in effect for you or your Spouse on the date we determine you are Terminally Ill up to the Maximum Benefit Amount shown in your Schedule of Benefits for this option. The Terminal Illness Benefit is payable only once in an Insured's lifetime. Determination of Terminal Illness For the purpose of determining the existence of a Terminal Illness, we will require you to submit the following proof. 1. A written diagnosis and prognosis by two Physicians licensed to practice in the United States. 2. Supportive evidence satisfactory to us, including but not limited to radiological, histological or laboratory reports documenting the Terminal Illness. We may require, at our expense, you to be examined and a review of the documented evidence by a Physician of our choice. "Terminal Illness" means a person is diagnosed by a Physician to have a prognosis of 12 months or less to live. TL Conversion Privilege for Life Insurance If coverage ends for any reason except non-payment of premium, any Insured may apply for a conversion policy of life insurance. The conversion insurance may be a type of life insurance currently being offered for conversion by us at your age and in the amount requested. It may not be term insurance and it may not be for an amount greater than the Life Insurance Benefits in force under the Policy. Conversion life insurance will not provide accident, disability or other benefits. However, if coverage ends because the Policy is terminated or amended to terminate any class of Insureds, or the Employer cancels participation under the Policy, coverage cannot be converted unless you have been insured under the Policy for at least 3 years. In this case, the amount of conversion insurance will be the lesser of Life Insurance Benefit in force under the Policy or $10,000. To apply for conversion insurance, you must submit an application to us and pay the required premium within 31 days after coverage under the Policy ends. Evidence of insurability is not required. Premium for the conversion insurance will be based on your age and class of risk and the type and amount of coverage issued. Conversion insurance will become effective on the 31st day after the date coverage under the Policy ends, if your application is received by us and the required premium is paid on that date. If you die during the 31 day conversion period, the Death Benefit will be paid under the Policy regardless of whether you applied for conversion insurance. If a conversion policy is issued, it will be in exchange for any benefits payable for that type and amount of insurance under the Policy. 5

20 Extension of Conversion Period If you are eligible for conversion insurance and are not notified of this right at least 15 days prior to the end of the 31 day conversion period, the conversion period will be extended. You will have 15 days from the date notice is given to apply for conversion insurance. In no event will the conversion period be extended beyond 90 days. Notice, for the purpose of this section, means written notice presented to you by your Employer or mailed to your last known address as reported by your Employer. If you die during the extended conversion period, but more than 31 days after your coverage under the Policy terminates, Life Insurance Benefits will not be paid under the Policy. If your application for conversion insurance is received by us and the required premium is paid, Life Insurance Benefits will be payable under the conversion insurance. Prior Conversion Limitation If you are covered under a life insurance conversion policy previously issued by us under the Policy, you will not be eligible to exercise this Conversion Privilege unless the prior coverage has ended. This does not apply to any amount of insurance that was previously converted under the Policy due to a reduction in your Life Insurance Benefits based on age or a change in class. TL LIFE INSURANCE EXCLUSIONS If an Insured commits suicide, while sane or insane, within 2 years from the date the Insured's insurance under the Policy becomes effective, Life Insurance Benefits will be limited to a refund of the premiums paid on the Insured's behalf. The suicide exclusion applies from the effective date of any additional benefits or increases in Life Insurance Benefits. If a Dependent Child commits suicide and is survived by other Dependent Children covered under your certificate, no refund of premiums will be paid. TL ACCIDENT INSURANCE BENEFITS If you are an Employee and insured under the Policy for Accident Insurance on the date of an Accident, we will pay the Accident Insurance Benefits for a loss shown in the Schedule of Losses. If more than one loss results from the same Accident, we will pay only the largest Benefit Amount to which you are entitled. The loss must be a result of bodily Injuries caused directly, and from no other causes, by an Accident, and must occur within 365 days of the Accident. Schedule of Losses Benefit Amount Life, or Two Members % One Member... 50% Thumb and Index Finger of the Same Hand... 25% 6

21 "Member" means a hand, foot or the entire sight of an eye. Loss of a hand or foot means complete Severance through or above the wrist or ankle joint. Loss of sight means the total, permanent loss of sight of the eye. The loss of sight must be irrecoverable by natural, surgical or artificial means. Loss of a thumb and index finger means complete Severance through or above the metacarpophalangeal joints (the joints between the fingers and the hand). "Severance" means the complete separation and dismemberment of the part from the body. TL ACCIDENT INSURANCE EXCLUSIONS We will not pay Accident Insurance Benefits for a loss which in any way results directly or indirectly from any of the following circumstances. 1. Suicide, attempted suicide or intentionally self-inflicted Injury, while sane or insane (Except in Missouri, this applies only while sane). 2. Sickness, disease or bodily infirmity; medical or surgical treatment; or bacterial or viral infection, no matter how contracted. (This does not include bacterial infection that is the natural and foreseeable result of an accidental bodily injury or accidental food poisoning.) 3. An Accident that occurs while engaged in the activities of active duty service in the military, navy or air force of any country or international organization. An Accident that occurs while engaged in Reserve or National Guard training is not excluded until training extends beyond 31 days. 4. Commission of a felony. 5. War or an act of war, whether or not declared. 6. Travel or flight in, or getting in or out of: an aircraft being used for test or experiment; an aircraft the Insured is flying, is learning to fly, or is part of the crew of; a military aircraft, other than transport aircraft flown by the U.S. Air Mobility Command (AMC) or a similar air transport service of another country; an aircraft owned or leased by or for the Employer, its subsidiaries or affiliates, or the Insured or a member of his or her household; an aircraft that does not have a valid FAA normal or transport type certificate of airworthiness; or an aircraft that is not flown by a pilot with a valid license. 7. Injuries arising out of, or in the course of, any work for wage or profit. TL CLAIM PROVISIONS Notice of Claim Written notice of claim, or notice by any other electronic/telephonic means authorized by us, must be given to us within 31 days after a covered loss occurs or begins or as soon as reasonably possible. If written notice, or notice by any other electronic/telephonic means authorized by us, is not given in that time, the claim will not be invalidated or reduced if it is shown that notice was given as soon as was reasonably possible. Notice can be given at our home office in Philadelphia, Pennsylvania or to our agent. Notice should include the Employer's name, the Policy Number and the claimant's name and address. Written notice of a diagnosis of a Terminal Illness on which claim is based must be given to us within 60 days after the diagnosis. If notice is not given in that time, the claim will not be invalidated or reduced if it is shown that written notice was given as soon as reasonably possible. 7

22 Claim Forms When we receive notice of claim, we will send claim forms for filing proof of loss. If we do not send claim forms within 15 days after notice is received by us, the proof requirements will be met by submitting, within the time required under the "Proof of Loss" section, written proof, or proof by any other electronic/telephonic means authorized by us, of the nature and extent of the loss. Claimant Cooperation Provision If you fail to cooperate with us in our administration of your claim, we may terminate the claim. Such cooperation includes, but is not limited to, providing any information or documents needed to determine whether benefits are payable or the actual benefit amount due. Insurance Data The Employer is required to cooperate with us in the review of claims and applications for coverage. Any information we provide to the Employer in these areas is confidential and may not be used or released by the Employer if not permitted by applicable privacy laws. Proof of Loss You must provide written proof of loss to us, or proof by any other electronic/telephonic means authorized by us, within 90 days after the date of the loss for which a claim is made. If written proof of loss, or proof by any other electronic/telephonic means authorized by us, is not given in that 90 day period, the claim will not be invalidated nor reduced if it is shown that it was given as soon as was reasonably possible. In any case, written proof of loss, or proof by any other electronic/telephonic means authorized by us, must be given not more than one year after the 90 day period. If written proof of loss, or proof by any other electronic/telephonic means authorized by us, is provided outside of these time limits, the claim will be denied. These time limits will not apply due to lack of legal capacity. Written proof of loss for Accelerated Benefits must be furnished 90 days after the date of diagnosis. This proof must describe the occurrence, character and diagnosis for which claim is made. In case of claim for any other loss, proof must be furnished within 90 days after the date of such loss. If it is not reasonably possible to submit proof of loss within these time periods, we will not deny or reduce any claim if proof is furnished as soon as reasonably possible. Proof must, in any case, be furnished not more than a year later, except for lack of legal capacity. Time of Payment Benefits due under the Policy for a loss, other than a loss for which the Policy provides installment payments, will be paid immediately upon receipt of due written proof of such loss. Subject to the receipt of satisfactory written proof of loss, all accrued benefits for loss for which the Policy provides installment payments will be paid monthly; any balance remaining unpaid upon the termination of liability will be paid immediately upon receipt of due written proof, unless otherwise stated in the Description of Benefits. To Whom Payable Death Benefits will be paid to the Insured's named beneficiary, if any, on file at the time of payment or to the certificate owner if alive. If there is no named beneficiary or surviving beneficiary, Death Benefits will be paid to the first surviving class of the following living relatives: spouse; child or children; mother or father; brothers or sisters; or to the executors or administrators of the Insured's estate. We may reduce the amount payable by any indebtedness due. 8

23 All benefits payable under the Accelerated Benefits section are payable to the Insured, if living. If the Insured dies prior to the payment of an eligible claim for an Accelerated Benefit, benefits will be paid in accordance with the provisions applicable to the payment of Life Insurance proceeds, unless the Insured has directed us otherwise in writing. However, any payment made by us prior to notice of the Insured's death shall discharge us of any benefit that was paid. All other benefits unless otherwise stated in the Policy, will be payable to the Insured or the certificate owner if other than the Insured. Any other accrued benefits which are unpaid at your death will, at our option, be paid either to your beneficiary or to the executor or administrator of your estate. If we pay benefits to the executor or administrator of your estate or to a person who is incapable of giving a valid release, we may pay up to $1,000 to a relative by blood or marriage whom we believe is equitably entitled. This good faith payment satisfies our legal duty to the extent of that payment. Change of Beneficiary You may change your beneficiary at any time by giving written notice to the Employer or to us. The beneficiary's consent is not required for this or any other change which you may make unless your designation of beneficiary is irrevocable. No change in beneficiary will take effect until the form is received by the Employer or us. When this form is received, it will take effect as of the date of the form. If you die before the form is received, we will not be liable for any payment that was made before receipt of the form. Physical Examination and Autopsy We may, at our expense, exercise the right to examine any person for whom a claim is pending as often as we may reasonably require. Also, we may, at our expense, require an autopsy unless prohibited by law. Legal Actions No action at law or in equity may be brought to recover benefits under the Policy less than 60 days after written proof of loss, or proof by any other electronic/telephonic means authorized by us, has been furnished as required by the Policy. No such action shall be brought more than 3 years after the time satisfactory proof of loss is required to be furnished. Time Limitations If any time limit stated in the Policy for giving notice of claim or proof of loss, or for bringing any action at law or in equity, is less than that permitted by the law of the state in which you live when the Policy is issued, then the time limit provided in the Policy is extended to agree with the minimum permitted by the law of that state. Physician/Patient Relationship You have the right to choose any Physician who is practicing legally. We will in no way disturb the Physician/patient relationship. TL

24 ADMINISTRATIVE PROVISIONS Premiums The premiums for this Policy will be based on the rates currently in force, the plan and the amount of insurance in effect. If an Insured's coverage amount is reduced due to acceleration of a Death Benefit, premium will be based on the amount of coverage in force on the day before the reduction took place. Your Grace Period If your required premium is not paid on the Premium Due Date, there is a 31 day grace period after each premium due date after the first. If the required premium is not paid during the grace period, insurance will end on the last day for which premium was paid. TL GENERAL PROVISIONS Incontestability All statements made by the Employer or by an Insured are representations not warranties. No statement will be used to deny or reduce benefits or as a defense to a claim, unless a copy of the instrument containing the statement has been furnished to the claimant. In the event of death or legal incapacity, the beneficiary or representative must receive the copy. After two years from an Insured's effective date of insurance, or from the effective date of any added or increased benefits, no such statement will cause insurance to be contested except for fraud or eligibility for insurance. Misstatement of Age If an Insured's age has been misstated, we will adjust all benefits to the amounts that would have been purchased for the correct age. Workers' Compensation Insurance The Policy is not in lieu of and does not affect any requirements for insurance under any Workers' Compensation Insurance Law. Assignment of Benefits We will not be affected by the assignment of your certificate until the original assignment or a certified copy of the assignment is filed with us. We will not be responsible for the validity or sufficiency of an assignment. An assignment of benefits will operate so long as the assignment remains in force provided insurance under the Policy is in effect. This insurance may not be levied on, attached, garnisheed, or otherwise taken for a person's debts. This prohibition does not apply where contrary to law. Clerical Error A person's insurance will not be affected by error or delay in keeping records of insurance under the Policy. If such an error is found, the premium will be adjusted fairly. TL

25 DEFINITIONS Please note, certain words used in this document have specific meanings. These terms will be capitalized throughout this document. The definition of any word, if not defined in the text where it is used, may be found either in this Definitions section or in the Schedule of Benefits. Accident The term Accident means a sudden, unforeseeable external event that causes you bodily Injury and occurs while your coverage is in force under the Policy. Active Service A person other than an Employee is considered in Active Service if he or she is able to perform all the activities another person of the same age and sex could normally perform and is not: 1. a patient in a hospital or hospice, or receiving outpatient care for chemotherapy or radiation therapy; 2. confined at home under the care of a Physician for sickness or injury; 3. unable to perform any of the activities of daily living expected of a person of the same age (i.e., mobility, transferring, feeding, dressing or toileting) without human supervision or assistance; 4. receiving disability benefits from any source due to his or her sickness or injury. Dependent Child Your unmarried child if he or she meets the following requirements: 1. A child 14 days of age but less than 19 years old; 2. A child who is 19 or more years old but less than 23 years old, enrolled in a school as a full-time student and primarily supported by you; 3. A child who is 19 or more years old, primarily supported by you and incapable of self-sustaining employment by reason of mental or physical handicap. Proof of the child's condition and dependence must be submitted to us within 31 days after the date the child ceases to qualify as a Dependent for the reasons listed above. During the next two years, we may, from time to time, require proof of the continuation of such condition and dependence. After that, we may require proof no more than once a year. The term "child" means a child born to or legally adopted by you. It includes a child during any waiting period prior to the finalization of the child's adoption. It also means a stepchild living with and financially dependent upon you. Employee For eligibility purposes, you are an Employee if you work for the Employer and are in one of the "Classes of Eligible Employees." Otherwise, you are an Employee if you are an employee of the Employer who is insured under the Policy. The term includes a retired Employee who satisfies the Class Definition shown in the Schedule of Benefits. Employer The Employer who has subscribed to the Policyholder and for the benefit of whose Employees this policy has been issued. The Employer, named as the Subscriber on the front of this Policy, includes any affiliates or subsidiaries covered under the Policy. The Employer is acting as your agent for transactions relating to this insurance. You shall not consider any actions of the Employer as actions of the Insurance Company. Insurability Requirement An eligible person satisfies the Insurability Requirement for an amount of coverage on the day we agree in writing to accept you as insured for that amount. To determine a person's acceptability for coverage, we will require you to provide evidence of good health and may require it be provided at your expense. 11

26 Insurance Company The Insurance Company underwriting the Policy is named on your certificate cover page. References to the Insurance Company have been changed to "we", "our", "ours", and "us" throughout the certificate. Insured You are an Insured if you are eligible for insurance under the Policy, insurance is elected for you, the required premium is paid and your coverage is in force under the Policy. Physician Physician means a licensed doctor practicing within the scope of his or her license and rendering care and treatment to an Insured that is appropriate for the condition and locality. The term does not include you, your spouse, your immediate family (including parents, children, siblings, or spouses of any of the foregoing, whether the relationship derives from blood or marriage), or a person living in your household. Prior Plan The Prior Plan refers to the plan of insurance providing similar benefits to you, sponsored by the Employer and in effect directly prior to the Policy Effective Date. Spouse Your current lawful spouse under age 75. TL

27 IMPORTANT CHANGES FOR STATE REQUIREMENTS If you reside in one of the following states, please read the important changes below. The provisions of your certificate are modified for residents of the following states. The modifications listed apply only to residents of that state. California Residents: Conversion Privilege for Life Insurance Insured Employees and Insured Spouses may convert to an individual policy of life insurance for an amount not greater than the Conversion Amount shown below when the Policy ends, without regard to any requirement that the person be insured under the policy for a specified period of time, if all of the following apply. a. The Insured became Totally Disabled while covered for the Life Benefit of the Policy. Totally Disabled means the person is unable to perform all the material duties of any occupation for which he or she may reasonably be qualified based on training, education and experience. b. The Insured remained Totally Disabled until the Policy ended while covered for the Life Benefit of this Policy. c. The Policy does not provide a Waiver of Premium, Extended Death Benefit Provision or monthly payments to Totally Disabled Insureds for the Life Benefit. d. The person meets all other conditions for converting the insurance. Conversion Amount - Insured s life insurance amount under the Policy on the date the Policy ends minus the amount for which the Insured is insured under a group policy that provides life coverage to employees of the Insured Employee s Employer covered under this Policy. The dollar limit that applies to the amount for conversion at Policy termination does not apply. The requirement that the Insured be covered under the Policy for the stated number of years in order to convert life insurance does not apply. Minnesota residents: The following Continuation of Life Insurance provision is applicable to Minnesota residents if the Employer has a minimum of 25 Employees who reside in Minnesota, the Minnesota Employees represent at least 25% of all covered Employees under the Policy, and the Policy does not offer Portability. Continuation Of Life Insurance This provision shall not apply to the extent that the Policy provides for the right of Employees to continue insurance on a direct billed basis following termination of employment (Portability). This provision shall apply with respect to Employees whose coverage under the Policy is terminated due to: (i) voluntary or involuntary termination or layoff from employment, for any reason other than gross misconduct; or (ii) reduction in hours such that the Employee is not eligible for insurance under the Policy. This provision shall only apply to Employees who, on such date, are Minnesota residents. For those Employees subject to this provision, life insurance coverage may be continued under the Policy for 18 months or until the date that the Employee becomes covered under another group policy, whichever is shorter. Coverage provided under this provision will also end if the Policy is terminated. 13

28 The premium required for continued coverage shall be the premium under the Policy applicable to the Employee s class and amount of coverage. The Employer may charge an additional amount, not to exceed 2% of such premium, for collecting premium contributions from former Employees. The Employer shall notify the Employee of the right to continue and the required premium contribution. The Employee may elect to continue within 60 days of termination by paying the required premium, and may continue coverage in force by paying the required premium, without demand, on a monthly basis, as of the first of each month, to the Employer. Coverage will end at the end of any month in which the Employee has failed to pay premium to the Employer. If continued coverage remains in force at the end of the 18 month period, or on termination of the Policy, the Employee may choose any conversion right then available under the Policy. In the event the Employee dies during the 60 day right to elect period without having become insured under another group policy, or dies while continued coverage is in force, the death benefit will be paid to the beneficiary chosen by the Employee under the terms of the Policy. Continued coverage will include eligible dependents who were covered on the Employee s date of termination, provided the dependent remains eligible as a dependent of the Employee. In the event that the dependent ceases to be eligible, the dependent may choose any conversion right then available under the Policy. Missouri residents: Applicable to Accident Insurance Benefits The Insurance Company will not pay Accident Insurance Benefits for a loss which in any way results, directly or indirectly, from suicide, attempted suicide or intentionally self-inflicted injury, while sane or insane, within 1 year from the date the Insured s coverage becomes effective under the Policy. If within 1 year from the date the Insured s coverage becomes effective under the Policy the Insured dies as a result of suicide, Accident Insurance Benefits will be limited to a refund of the premiums paid on the Insured s behalf. Applicable to Voluntary Life Insurance Benefits If an Insured commits suicide, while sane or insane, within 1 year from the date his or her insurance under the Policy becomes effective, Voluntary Life Insurance Benefits will be limited to a refund of the premiums paid on the Insured's behalf. The suicide exclusion applies from the effective date of any additional benefits or increases in Life Insurance Benefits. Except for any amount of benefits in excess of the Prior Plan's benefits, this exclusion will not apply to any person covered under the Prior Plan for more than one year. If a person was not insured for one year under the Prior Plan, credit will be given for the time he or she was insured. If a Dependent Child commits suicide and is survived by other Dependent Children covered under the same certificate, no refund of premiums will be paid. 14

29 North Dakota residents: The Suicide exclusion, if any, is limited to one year from the effective date of insurance. The suicide exclusion with respect to any increase in death benefits which results from an application of the insured subsequent to the effective date, if any, is limited to one year from the effective date of the increase. Texas residents: The coverage amount for an Employee under all Employer-sponsored group life programs is limited to seven (7) times his or her salary, or $250,000, whichever is greater. If the Employee s Spouse and/or Dependent Children are eligible for coverage, their coverage amounts are subject to the same limit. 15

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32 UNDERWRITTEN BY: LIFE INSURANCE COMPANY OF NORTH AMERICA a CIGNA company Class 2 05/2013